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HomeMy WebLinkAbout1101A 1102A (5) WORKERS'COMPENSATION DECLARATION "� I hereby affirm that I have a cer}ificate of consent to self qpp`�CATION FOR BUILDING PERMIT insure,or a certifimte of Workers'Compensation insurance, or a cerlified copy ihereof(Sec.3800,Lob.C.) COUNTY OF LOS ANGELES BUILDING AND SAPETY PolicyNo61WBRIC448�ompany HAKTFORD GROUP � Ce�tified mpy is he�eby furnished. FOR APPLICANT TO FILL IN aunoiNc, c� �Jp � 'fj ADDRESS � /�`� • LO�i.-��T<^��' �{�',2" � Certified topy is filed with ihe county building inspeo- BUu�ING tion deparlmenL ADDRESS � LOCALITY �•�• Date�B�n ucanr _ . X. aTv DIAMOND BAR NeAaesr PP ZIP CROSS 57. CERTI ICATE OF EREMP710N FROM WORKERS' NO.OF s�oGS. a55E5SOR COMPENSATION INSURANCE SRE OF�Oi NOw ON tOi MAP 800K PAGE PARCEL (This section need not be completed if Ihe permif is for one 1 USE)ONE MAP )`/ .3 hundred dollars($100)o�less.) TRACT BLOCK LOT �e�aJ No. 'i �'' I certify�hm in the pertormance of the work fo�which this owNeR BRAMALEA LIMITED No.$50-1��1 o�f)Oa CONDITIOnlS � permit is issued,I sholl noi employ any person in any mpnner 3151 �1IRWAY AVE. SUITE N D�S7RICT GROUP TVPE FIRE PROCESSE�BV � so as to hecome subjecf fo fhe Workers'Compensation Laws. ADDRE55 (� �T�CONST.� � � �are A limnt arv COSTA MESA, CA. ziv 92626 � � PP STATISTICAL CtA551FICATION APT. CON O. NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT oR TEL LF .y,t � " tion, ENGINEER NO. - $ CLA55 NO. � DWELL UNIiS � � � p' you shoold become su6ject to ihe Workers' pensation provisions of the Labor Code,you must£orih- qDDRE5S3J9O «EST�RLY PL. �IL�O NL'WPORT BC . SEWER MnP "'� wit comply with such provisions or ihis permil shall be �; deemed re�oked. coNrkncTorzSRtlP�f1LEA CALIE. Np sK. v�, VALIDA71tlN � LICENSED CONTRACTORS DECLARATION ,��� I hereby affirm fhat I am licensed under provisions of Chapfer 9 ADDRE55 3151 AIRWAY AVE. rvo. 409610 YALUATION (commencing with Section 7000)of Division 3 of the Business and ���, >` i J.� � Professions Code,and my license is in fuli force and effed. CITY CQ$T,� T'�'$A C/�.. 92626 CL4S5 B $ ��f � Q , � SQ.FT. NO.OF NO.OF CHECK �.;a w .. o�j License Number 409610 �;�.class B s¢e sroRiEs FnMaies orve T�' �(��L�,�-" DESCRIPTION OF WORK 23 B NEW s� $ � '�%G O,�` 1 Contracto�_ BRA.�ALEA CALIF.Date I ❑I am exempt under Sec. �r SINGLE FAMILY RESIDENCE ADD � ' ��`��"� ' � AI.TER � FINAL B.SP.C.for this reason NEW CONSTRUCTION REPAIR � DATE �'�� / U l,(,�%"�'rJ I Date: USE OF NONE � FINAL EXISTING BLDG. DEMOL B $ignafure • APP��CANT TEL. Y OWNER-BUILDER DECLARATION PRINT SRUC� L. ABBEY NO, - OL c_� 1 (1 C A . I here6y affirm that I am exempt from the Comra ' ' nse 3151 AIRWAY AV�. N. COSTA MF,SA C . , �, Law for the following reason(Sedian 7031.5, usiness and /+DDRESS 7.f,� a c o a � I Professians Code): PRESENT ���. � BUILDING I °v Q.Q�L' I, as owner of the properiy, or my employees with PDURESS wages as iheir sole compensation,will do the work and � t�ll�1,�j(��;, the structure is not intended or offered for sale(Section �OCALI7v , 7044,Business and Professians Code). MOVING TEL. � I,ps owner of the property,am exdusively conhacfing CONTRACTOR NO. � /.C[-s '�,r` wifh licensed coniraciors ro construct the project(Sec- qDDREss tion 7044,Business and Professions Code). REQUIRE� TOTAL SETBAIX FROM EXIST. CONSTRUCTION IENDING AGENCY SET BACK VARD Hwv pROP.LIN WiDiti , I hereby affirm that there is a construction lending agency for FRONT ihe parformonce of the work for which this permit is issued P.L. (Sec.3097,Civ.C.). SIOE P.L. �endei s Name TORONTO ➢OMINION liANK $ P.C.Fee S ��O� T I P¢rmit Fea �.'2�rJ^-�� lendeisAddress SAN FRANCISCOy•CAL. 941�Lt / � I certify that I have read this application and state}hat the Issuance Fee 6 t��� ¢ above information is correcf.I agree fo tomply with all Counfy Investigoiion Fee ,/�e �� `� ordinances and$tafe lows relating to boilding tonstruction, Total Fee �7 �i and hereby authorize representatives of this Coumy to enter � upon ihe above-meniioned properry for inspection purposes. � /O� ��A� �� � -'�'(� d1 ///��� f� 6 y'��t__ -�g, � (�f7/f�+j�- SEE REVERSE FOR EXPlANA70RY LANGUAGE Signatura of Applicam or Agent �Dot�-'� m, �._.---------------------�--- — ..__ .�_ _....-- - _ _._—_-- - ---- _ _ —�-- ,� v._ S----'- y m-n� — m -n cn �t �T7 � Cn -O _n r � ..�1 i �� �t � �3� 00` 0 0 � � � o p mo� � � n yia�����'.��Q_:._�Y�__Q .I � � �� � o i� Q � s �Y S 3 � 7�CT:. x � e � � n m � � '�-, t� �.�; i i o I °L � � p K �D Q I° o k� � Q. � ;�Q �� � cQ. � � � 3 n � � � . 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